| NPI | 1013934603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA02695) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 000099) |
| 363A00000X Physician Assistant (Licence: NY 001392) | |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2011-05-13 |